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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH' ITMENT 304 E WEBER AVE-311°FL-ST -ON CA 95202 -(209)468-3420 ! <br /> NON-REFUNDABLE PERMIT ALL(209)953-7697 FOR INSPECTIONS EXPIR EAR FROM DATE ISSUED <br /> JOBADDRESS - -' :•1� ¢ I- CITYIZIP V_I �. i e <br /> CROSS STREET t' - 5-" APN f -j' { PARCEL SIZE <br /> v <br /> Im OWNER NAME '{ sA'1' n-I" (.. G 1 r PHONE <br /> OWNER ADDRESS <br /> {t 4. I,; "-I�:. i ;; ..� f. CrrYISTATEIZ.IP <br /> - <br /> CONTRACTOR I-J:: I ri I -+ 1 PHONE <br /> nJ <br /> CONTRACTDRAnnRESS CR'YISTATUZIP I_ <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER ExPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST N I BUILDING PERMIT# LAND USE APPLICATION# I'f1 <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED IALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER -. <br /> Ir NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBEROF EMPLOYEES: _ <br /> ❑ SEPTIC TANK TYPFJMFO CAPACrry gal N OF COMPAICZENTS <br /> ❑ GREASE TRAP TYPE/Mm CAPACITY gal k OF COMPARTMENTS - <br /> ❑ PKG TX PLANT DISTANCE To NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OP PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS 0 OF LINES LENGTH OF LfNES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> a FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETONEARE5T WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> JIM DISTANCE To NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH n DEPTH ft <br /> DISTANCETONEARE37• WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH R 1 <br /> DISTANCETONEARE5T WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTD ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY J <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> -MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED i �f:`L 7 -.._. _ _ TITLE I - DATE <br /> ..•. mow'�,� �` _ <br /> 71: l I 1 1 , <br /> 1 <br /> E VI or M Nf <br /> ae' <br /> �11 <br /> i <br /> $ 3...`-c�•� DEPARTMENT II F(INLY - 2 <br /> 13 LS y I JJ <br /> Application Accepted By _ `. Date _._ Area F.nulloyee lD� <br /> FinalInsperlionBy ---� _ f' T^ -Datr -_ ❑ SPECIAI,PERMIT-Approved 6y . <br /> (ilarietcr of Suit to Depth of 3 Ft: Pit/Sump Soil Ch arectcr: <br /> PE 5C Received LChegl*/- Amount Permit! <br /> Code INF. B Cash Remitted Date Servlce Re uest M invoice N Permit 1RlI <br /> Cao _ <br /> I <br /> 42-02-001 - ONSITE WASTEWATER PERMIT <br /> IL2212W3 <br />